HospitalInspections.org

Based on record review and interview, the facility failed to ensure a patient's name, a permanent medical record number and date of birth was documented correctly for 1 of 3 (Patient #2) sample patients who had blood and urine samples sent to the hospital laboratory.

The findings included:

1. Medical record review for Patient #2 revealed an outpatient laboratory service completed on 9/3/2021 for a diagnosis of Urinary Tract Infection and Hypertension.

A physician's order dated 9/3/2021 revealed, "...CBC [Complete Blood Count] & [and] UA [Urine Analysis] c [with] culture..." The physician's order was handwritten and Patient #2's date of birth was incorrect.

Review of Patient #2's face sheet revealed the correct name, birthdate and medical record number.

Review of a cumulative final report for Patient #2 revealed laboratory results for a complete blood count. The name listed on the report was Patient #4's name, medical record number and birthdate.

The hospital confirmed Patient #4 was not seen as an outpatient or inpatient on 9/3/2021.

Review of an Antimicrobial Susceptibility and Organism Identification Report dated 9/3/2021 revealed Patient #2's correct name, with an incorrect medical record number (belonging to Patient #4) and an incorrect birthdate (belonging to Patient #4).

In an interview with the Patient Financial Service Director on 10/1/2021 at 11:18 PM in the administrative conference room, the Patient Financial Service Director stated the person registering Patient #2 may not have had enough information so she created a new record, because Patient #2 maybe had not been here before. When she realized Patient #2 had been here before she changed it to the correct medical record number, but did not realize it was entered into the computer using an incorrect digit. It was off by one (1) digit. On the 8th of September somehow she changed the history again, so that anything that was documented between the 3rd and the 8th of September was hitting the wrong account. The documentation did not roll with the correction. The Patient Financial Service Director confirmed she was not notified of the discrepancy until this interview.

In an interview with the Chief Nursing Officer and the Director of Quality, Process Improvement and Risk Management on 10/1/2021 at 11:40 AM confirmed they had not been notified of this coding discrepency.

Based on record review and interview, the facility failed to ensure documentation was accurate for intravenous (IV) infusion sites for 1 of 3 (Patient #1) sample patients reviewed.

The findings included:

Medical record review for Patient #1 revealed an admission date of 8/28/2021 and discharged on 9/10/2021 with diagnoses which included Cerebral Vascular Accident with Right Upper Extremity weakness and Altered Mental Status.

Review of the Clinical Documentation Report revealed Patient #1 had an IV on 8/28/2021 at 11:37 PM and on 8/29/2021 at 10:41 AM:
#1 right antecubital site without edema, tenderness or erythema. On 8/30/2021 a nurses note revealed a second IV was started in the Right Upper Arm. (Right Forearm)
On 8/30/2021 at 9:22 AM and 10:32 PM, 8/31/2021 at 8:52 AM:
#1 Right Antecubital and #2 Right Forearm sites without edema, tenderness or erythema.

On 8/31/2021 at 10:38 PM there was no documentation regarding the location of the IV sites.

On 9/1/2021 at 8:22 AM: #1 Right Upper Arm and #2 Right Antecubital without edema, tenderness or erythema. Identification #'s were transposed.

On 9/1/2021 at 3:30 PM both IV's were discontinued.

Review of the Clinical Documentation Report revealed Patient #1 had an IV inserted to left hand on 9/1/2021 at 4:00 PM.

On 9/2/2021 at 3:43 AM there was no documentation regarding the location of 1 IV site.

On 9/2/2021 at 9:04 AM: #1 Left hand without edema, tenderness or erythema.

Review of a general note dated 9/2/2021 at 9:24 AM revealed, "IV Site Discontinued: to left hand"

Review of a general note dated 9/2/2021 at 9:25 AM revealed, "...Family called and reported IV infiltration. Arrived in the room. Family at bedside appeared upset that IV site is infiltrated. IVF [Intravenous fluid] stopped and IV site d/c [discontinued]. Attempted to reassure family and explained that infiltration is one of the risks with continuing infusion of IV fluids. Family verbalized dissatisfaction and stated, "I can not believe that you let this happen to my mother. I left her yesterday and she was fine and today I came in and found this. I need to see [Named Nurse Practitioner] NOW!" Provider notified about family request..."

There was no documentation of the site location of the IV restarted on 9/2/2021.

Review of the Clinical Documentation Report revealed on 9/2/2021 at 7:52 PM, 9/3/2021 at 9:57 AM and 9/3/2021 at 8:32 PM: #1 Left hand without edema, tenderness or erythema.

The site changes to Left Antecubital. There was no documentation of any IV site changes.

Review of the Clinical Documentation Report revealed on 9/4/2021 at 7:23 AM, 9/4/2021 at 11:00 PM: #1 Left Antecubital without edema, tenderness or erythema.

The site changes to Left Hand on 9/5/2021. There is no documentation of any IV site changes.

Review of the Clinical Documentation Report revealed on 9/5/2021 at 7:48 AM: #1 Left Hand without edema, tenderness or erythema.

Review of the Clinical Documentation Report revealed on 9/6/2021 at 12:07 AM, 9/6/2021 at 8:16 PM: #1 Left Hand without edema, tenderness or erythema.

Review of a nurses note dated 9/7/2021 at 1:48 AM revealed an IV insertion to Left hand.

There was no documentation that the previous IV also documented in the Left hand had been discontinued.

Review of the Clinical Documentation Report revealed the IV was in the left hand until discharge on 9/10/2021 with no edema, tenderness or erythema.

During an interview on 10/1/2021 at 1155 AM, the Director of Quality, Process Improvement and Risk confirmed the IV documentation was confusing for Patient #1.